Understanding Bipolar Psychoses

When I wrote about my brother’s disappearance, it was THE hardest post I ever had to write. That night, I didn’t sleep at all as I rarely discuss openly that he is bipolar, especially because, when on his meds, he is perfectly normal. However, the very next day, I was overwhelmed with texts, comments on the post, emails, phone calls, etc. of people who also have had someone close to them who has a mental illness, specifically bipolar. Up until that point, I had felt a little lonely with what my family has had to endure over the years prior to his diagnoses and being treated, and now continues to endure in a very painful way since my brother went off his meds and has been missing for two months now. Originally we had been given a lot of information regarding his whereabouts that we soon learned was false (including one particular person who posed as two people giving us false leads that we only realized were a hoax after flying into San Francisco and putting together an organized search based on this person’s cruelty). In fact, Cameron Remmer officially has never been seen or heard from since October 6. Though even the Fairmont Hotel told us that he had been back on the 9th, once my older brother watched the surveillance tape, this also turned out to be untrue. And of course the absolute worst was being told by the San Francisco police on Halloween he had been found, having his doctor call from San Diego to the hospital where “he” was held and prescribe meds, elated he was safe, only to find out many hours later it was someone claiming to be Cameron. After many long days, nights and tears, my family has reached an understanding that he has likely chosen to disappear or perhaps, because of his current mental state off his meds, doesn’t even realize he is “missing.” When it comes to being bipolar in general, Breezy Mama turned to Dr. Dawnmarie Risley — a seasoned psychiatrist who cares primarily for those with bipolar and schizophrenic illnesses — to understand better what many of us, I’ve come to learn, are going through together.

What is the difference between bipolar 1 and bipolar 2?

Time requirements and impairment. Someone with bipolar 2 has had a manic episode that lasts 4 days or more, but is not severe enough to cause significant impairment that may be cause for hospitalization. A patient with bipolar I disorder has had a manic episode that lasts for a week or more, and causes significant impairment that may be cause for hospitalization. Although, in my line of work, I consider having had an arrest due to an incident where judgment is impaired because of symptoms, to be impairment to justify a diagnosis of bipolar I.

Can both have psychoses?

Yes. While psychosis is not part of the “criteria” for bipolar, I have seen patients with psychotic symptoms while in a manic episode. If the psychosis remains between episodes, then a diagnosis of schizo-affective disorder, bipolar type, is more fitting. Usually, when in a manic episode, a patient may have grandiose delusions. Examples I have heard from patients include, believing he/she is Jesus Christ, a disciple of Jesus, on secret missions for the CIA, 5 Star military generals, and a patient who believed she could make herself invisible by concentrating really hard. I have had patients that have had paranoid delusions, and that could hear or see things that others could not, while in a manic episode.

When a patient has grandiose delusions (such as believing they are Jesus) that is schizo-affective disorder?

No. Grandiose delusions are one of several criteria for a diagnosis of a manic phase.

Can you explain what is going on during the psychotic phase?

When a patient is psychotic, he/she may have hallucinations and/or delusions. Patients may hear voices, usually “outside” their head, sometimes in whispers, of one or multiple voices, talking to one another, talking about the individual, telling the individual what to do, or generally very derogatory to the individual. When men hear voices, their voices are generally derogatory regarding their manhood. One of my patients confronted me while I was walking in front of him, “Dr. Risley, Why did you just call me a [expletive]?!” We discussed that that was his voices calling him names. Women typically hear things that make reference to their chastity or virtue.

My 3 brothers and my nephew.

Why do people who are bipolar disappear? Is disappearing premeditated? Are they always in a psychotic state when they disappear?

This is an interesting set of questions. I’m not aware that patients with bipolar disorder disappear. If anything, they usually want to be around others, not go off alone. Patients in a manic episode sometimes like to travel. Once in my residency in California, I called a doctor in South Carolina, informing him that I had his patient in my ER in Southern California. She was in Cali to visit her long lost daughter, whom she hadn’t spoken to in over 15 years, let alone did she know her current address. I’ve also had a patient who had moved to about 5 different states, each about 500 miles from one another, which she described was for her job. She was a waitress. And yet another example, I was called to consult on a patient in the parking lot. The resident described him as a tall older man who left the hospital and he (the resident) wanted my assistance. I guessed from the description of his behaviors that the patient was in a manic episode. When I arrived at the parking area, no one was in sight, but I noticed there was a party going on at the children’s hospital entrance. I thought to myself, “If I were in a manic episode, where would I want to be? Where all the action is.” As I was walking toward the celebration, there was a man in a wheelchair talking the ear off of some passerby. I knew that not only did the consulting resident had not ever seen the patient, but I knew that that was my patient!

Is it possible my brother isn’t aware that he’s disappeared? He just fell out of contact?

Yes. Especially if he is psychotic.

Can you explain why it is so common for someone who is bipolar to go off their meds?

Why is anyone non-compliant? Statistics show that only 50% of all patients actually fill their prescriptions, regardless of who prescribes them (psychiatrist vs family practitioner or surgeon). Of those who fill them, only about 50% of those patients take them exactly as prescribed. The other half may take their medications, but not necessarily as prescribed. So this is a general patient concern, not just for those with bipolar disorder. Aside from the stats, some don’t like the way they feel. They feel their minds are slowed, they feel stiff, their minds are dull, they have side-effects that aren’t tolerable. There can be any number of reasons, but these are some common complaints. Another reason, “I feel fine. There is nothing wrong with me.” Some don’t believe that they have bipolar disorder, and some don’t remember their manic episode at all. I have also had patients in the prison, who have converted to Islam, and will not take their medications during Ramadan because they are fasting. This generally leads to a manic episode very soon. Others are ill-advised by family members or non-healthcare professionals to stop their medications. Psychiatric medications hold tremendous stigma for those who are poorly informed about the topic.

How long can they maintain a mental state of well being once they stop taking their meds?

Patients sometimes “feel better” shortly after stopping their medications. Unfortunately, frequently, within a few weeks, manic symptoms will reappear.

Cam joking around with my husband at my daughter's ballet recital.

What is the best approach a family can take in order to encourage someone who is bipolar or even just depressed to stay medicated?

The best thing they can do is get educated about the illness! When family is informed and understands that this is an illness, that the violence that they have seen from their family member is not to be taken personally, that the person is just ill and needs their help, the family can serve as a big support. It is frequently the stigma that family places on the patient that causes the patient to stop medications.

I’ve read that some people believe they can “self medicate” with marijuana and it helps tone down the manic phases. I’ve also read it can be detrimental to increasing paranoia. What is your opinion on people who are bipolar smoking marijuana? And does your answer change for bipolar 1 and 2?

A lot of people believe that they can self-medicate with marijuana, no matter what the diagnosis. I find that some of the biggest pot smokers are those with anxiety disorders. Marijuana keeps the person from thinking. It “shuts” the mind down briefly. While I am not aware of any scientific evidence that supports this, my sense is that patients in a manic episode utilize marijuana to give themselves relief from their racing thoughts. There is an ever growing body of evidence that chronic marijuana use, in addition to methamphetamine use, leads or at least puts at risk, the development of schizophrenia, a psychotic disorder.

What about alcohol? Can someone who is on their meds drink alcohol if they are bipolar 1? And what about bipolar 2? Does your answer change if they are off their meds?

Patients with any mental disorder should avoid alcohol, on or off of medications. Alcohol increases the risk of violence in these patients (or for anyone for that matter!)
Once family is aware the person is off their meds, what is the best approach to encourage them to be back on?

Find out what the want is of the patient and utilize that as a means to gain what his/her goals are. Perhaps the patient just doesn’t like the stiff feeling that he gets from Risperdal, or the weight gain from Zyprexa? Find out the reason for stopping, and utilize that reason to get back on meds. Perhaps a medication change is what is needed. If Zyprexa is making the patient too fat, then perhaps dietary changes can be made, start an exercise program, or change to a different medication such as Lamictal, which is generally weight neutral.

What are the steps for obtaining conservatorship?

[This answer is provided by my husband, Jerry F. Childs, Esq] In the state of California, the potential Conservator files a petition with probate court seeking appointment as a conservator. Usually, a person who wishes to be conservator files a petition with the local probate court. There are temporary and permanent conservatorships. There are also two types of conservatorships: (1) of the person; and (2) of the estate. Appointment as a permanent conservator can take weeks or even months because it is a court process, with a court investigator, and any family members may object. I highly recommend that anybody get an attorney for this.

Once obtained, who does the family call once they are aware the person is off their meds?

The Court Order and the Letters of Conservatorship define the powers of the conservatee in this regard. The authority for medical treatment is closely defined. It may be necessary to go ex parte (without proper notice, ie. “I have an emergency, court, get this in order”) in order to get court authority to administer meds.

What is the best approach for dealing with someone in a manic phase?

If a patient is violent, or a danger to himself in someway, whether that be physically, or financially (having emptied his bank account to buy 7 new cars), then one can call 911 and let them know of the emergency. In California, someone who is a danger to himself, a danger to others, or gravely disabled, can be held in a psychiatric facility for up to 72 hours for evaluation, or longer if he/she still meets that criteria. It may be best just to leave it up to the professionals, as you can be putting yourself in harms way when a patient is manic and irritable.

When someone is bipolar, what do they wish their family understood about them?

Unfortunately, many who have had manic episodes aren’t aware themselves about what they have gone through. I have had countless patients tell me that the things that I told them they did, didn’t happen at all. I have often wondered what kind of impact video-taping an individual in a manic state would have on the patient. Would they learn the truth about themselves? Others remember exactly what had gone on, and are deeply sorry for the things that they said or did in the manic episode. Having the family accept that this is an illness, that is treatable, can support the patient in many ways.

My family’s impression is that my brother may be hiding from us because he knows we will put him back in the hospital.

It is very possible that he has left because he knows that your family will have him hospitalized. Manics generally don’t appreciate containment. Unfortunately, with all the cuts to outpatient services for the mentally ill that have taken place in the past 20+ years, too many get themselves into trouble, get thrown into prison, and are confined to cells. While Lantermann-Petris-Short (least restrictive environment) is necessary so as to not permanently institutionalize the mentally ill, we have just trans institutionalized these individuals from the mental health hospitals to the prisons.

About Dr. Risley Dr. Risley is seasoned psychiatrist having held licenses and practiced in Oregon, Connecticut, New York and California. She currently treats post-risk youth in her private practice in Fresno, Ca and psychiatrically ill inmates in the California Department of Corrections. In her free time, she enjoys flying and her growing family.

Comments

Chelsea, once again thanks for sharing. Given the heartbreak you and your loving family are suffering I know this must be hard on you.
Having been diagnosed bipolar type 1 years ago I know how much the help of a loving family can mean to someone with the disorder. Even I, with my knowledge of the disorder, fail to understand why Cameron has walked away from this.
I complement you on the interview with Dr Risley. You have both used this opportunity to present excellent insight into what it is like to be involved with bipolar disorder. It covers both sides of the coin. I mean here from the point of view of the afflicted and their loved ones.

Chelsea, I’ve known Cam my entire life and just want to thank you so much for posting the articles you’ve written about him. We’ve been friends since we were kids and it’s crazy that I never knew all of this about him. We go a couple yrs without contact and then he always calls/txts or just pops back into my life. He emailed me when he was hospitalized and I only knew what he told me which wasn’t much. He’s like a little brother to me and we had just started getting close again right before he disappeared…which just makes it that much harder =( You guys are in my prayers and my thoughts daily and I have faith he will be home soon! Lindsey xoxoxo